- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $158.61 / $158.61 / $183.01
| Professional | | $158.61 | $158.61 | $183.01 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $184.91 / $184.91 / $238.89
| Facility | | $184.91 | $184.91 | $238.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $134.97 / $184.91 / $197.12
| Professional | | $134.97 | $184.91 | $197.12 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $184.91 / $184.91 / $238.89
| Facility | | $184.91 | $184.91 | $238.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $134.97 / $184.91 / $197.12
| Professional | | $134.97 | $184.91 | $197.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $108.10 / $192.53 / $375.73
| Professional | | $108.10 | $192.53 | $375.73 |